New Jersey Office of Attorney GeneralDivision of Consumer Affairs

Legalized Games of Chance Control Commission124 Halsey Street, 6th Floor, P.O. Box 46000

Newark, New Jersey 07101(973) 273-8000

Instructions for Filing the Bingo Report of Operations Pursuant to N.J.A.C. 13:47-9.1, licensees are to file a report of operations with the Legalized Games of Chance Control Commission no later than the 15th day of the calendar month immediately following the calendar month in which the licensed activity was held, operated or conducted.

You must download this report and complete ALL of the entries for each occasion(s) relating to each bingo game. Once completed, a member/officer must certify that he/she has reviewed the report and that the information provided is true, accurate and complete. This will require the person to state his/her name and title, and that person must complete the information on page 3 and have the report notarized.

The Bingo Report of Operations is to be mailed to the Legalized Games of Chance Control Commission, P.O. Box 46000, Newark, New Jersey 07101, or emailed to AskGames@dca.njoag.gov .

It is recommended that you maintain a copy of all reports as part of the organization’s records.

New Jersey Office of Attorney GeneralDivision of Consumer Affairs

Legalized Games of Chance Control Commission124 Halsey Street, 6th Floor, P.O. Box 46000

Newark, New Jersey 07101(973) 273-8000

Bingo Report of Operations

Please print clearly. Identification number (format ###-##-#####) ________________________

Municipality ______________________________________ License number ______________________

Name of licensee _____________________________________________________________________________Organization

___________________________________________________________________________________________ Street address City State ZIP code

Location of games ____________________________________________________________________________

This report, as required by N.J.S.A. 5:8-37 and N.J.A.C. 13:47-9, must be filed with the Legalized Games ofChance Control Commission no later than the 15th day of the month following the conduct of the game(s) of chance.

Occasion 1 Date ____________________ Time _____________________ Number of players __________1. Regular games sales $ ___________ 10. Regular games payout $ __________ 17. Rentals $_________ 2. Special games sales $ ___________ 11. Special games payout $ __________ 18. Supplies/equip. $_________ 3. 50/50 Bingo games sales $ ___________ 12. 50/50 Bingo games payout $ __________ 19. Comp. Workers $_________4. Multicolor games sales $ ___________ 13. Multicolor games payout $ __________ 20. Total expenses $_________ 5. Progressive games sales $ ___________ 14. Progressive jackpot/cons. $ __________ 6. Predraw games sales $ ___________ 15. Predraw payout $ __________ 7. Electronic hand-held sales $ ___________8. Admission cards $ ___________

9. Total sales $ ___________ 16. Total payout $ __________ 21. Net proceeds $_________

Occasion 2 Date ____________________ Time _____________________ Number of players __________1. Regular games sales $ ___________ 10. Regular games payout $ __________ 17. Rentals $_________ 2. Special games sales $ ___________ 11. Special games payout $ __________ 18. Supplies/equip. $_________ 3. 50/50 Bingo games sales $ ___________ 12. 50/50 Bingo games payout $ __________ 19. Comp. Workers $_________4. Multicolor games sales $ ___________ 13. Multicolor games payout $ __________ 20. Total expenses $_________ 5. Progressive games sales $ ___________ 14. Progressive jackpot/cons. $ __________ 6. Predraw games sales $ ___________ 15. Predraw payout $ __________ 7. Electronic hand-held sales $ ___________8. Admission cards $ ___________

9. Total sales $ ___________ 16. Total payout $ __________ 21. Net proceeds $_________

Occasion 3 Date ____________________ Time _____________________ Number of players __________1. Regular games sales $ ___________ 10. Regular games payout $ __________ 17. Rentals $_________ 2. Special games sales $ ___________ 11. Special games payout $ __________ 18. Supplies/equip. $_________ 3. 50/50 Bingo games sales $ ___________ 12. 50/50 Bingo games payout $ __________ 19. Comp. Workers $_________4. Multicolor games sales $ ___________ 13. Multicolor games payout $ __________ 20. Total expenses $_________ 5. Progressive games sales $ ___________ 14. Progressive jackpot/cons. $ __________ 6. Predraw games sales $ ___________ 15. Predraw payout $ __________ 7. Electronic hand-held sales $ ___________8. Admission cards $ ___________

9. Total sales $ ___________ 16. Total payout $ __________ 21. Net proceeds $_________

Occasion 4 Date ____________________ Time _____________________ Number of players __________1. Regular games sales $ ___________ 10. Regular games payout $ __________ 17. Rentals $_________ 2. Special games sales $ ___________ 11. Special games payout $ __________ 18. Supplies/equip. $_________ 3. 50/50 Bingo games sales $ ___________ 12. 50/50 Bingo games payout $ __________ 19. Comp. Workers $_________4. Multicolor games sales $ ___________ 13. Multicolor games payout $ __________ 20. Total expenses $_________ 5. Progressive games sales $ ___________ 14. Progressive jackpot/cons. $ __________ 6. Predraw games sales $ ___________ 15. Predraw payout $ __________ 7. Electronic hand-held sales $ ___________8. Admission cards $ ___________

9. Total sales $ ___________ 16. Total payout $ __________ 21. Net proceeds $_________

Occasion 5 Date ____________________ Time _____________________ Number of players __________1. Regular games sales $ ___________ 10. Regular games payout $ __________ 17. Rentals $_________ 2. Special games sales $ ___________ 11. Special games payout $ __________ 18. Supplies/equip. $_________ 3. 50/50 Bingo games sales $ ___________ 12. 50/50 Bingo games payout $ __________ 19. Comp. Workers $_________4. Multicolor games sales $ ___________ 13. Multicolor games payout $ __________ 20. Total expenses $_________ 5. Progressive games sales $ ___________ 14. Progressive jackpot/cons. $ __________ 6. Predraw games sales $ ___________ 15. Predraw payout $ __________ 7. Electronic hand-held sales $ ___________8. Admission cards $ ___________

9. Total sales $ ___________ 16. Total payout $ __________ 21. Net proceeds $_________

Occasion 6 Date ____________________ Time _____________________ Number of players __________1. Regular games sales $ ___________ 10. Regular games payout $ __________ 17. Rentals $_________ 2. Special games sales $ ___________ 11. Special games payout $ __________ 18. Supplies/equip. $_________ 3. 50/50 Bingo games sales $ ___________ 12. 50/50 Bingo games payout $ __________ 19. Comp. Workers $_________4. Multicolor games sales $ ___________ 13. Multicolor games payout $ __________ 20. Total expenses $_________ 5. Progressive games sales $ ___________ 14. Progressive jackpot/cons. $ __________ 6. Predraw games sales $ ___________ 15. Predraw payout $ __________ 7. Electronic hand-held sales $ ___________8. Admission cards $ ___________

9. Total sales $ ___________ 16. Total payout $ __________ 21. Net proceeds $_________

Date

Schedule of Expenses

Description Check number Amount

Date

Utilization of Net Proceeds

Description Check number Amount

Name

Bank

Address where balance is deposited Account number

Name

Person Responsible for Use of Proceeds

Address Telephone number(include area code)

I certify that all of the statements on this report of operations are true, accurate and complete. I am aware that if any of the foregoing statements are willfully false, I am subject to punishment.

N.J.S.A. 5:8-37 “It shall be the duty of each licensee to maintain and keep such books and records as may be necessary to substantiate the particulars of each such report.”

I certify that I have reviewed this report and that the information on this report of operations is true, accurate and complete. I am aware that if any of the foregoing statements are willfully false, I am subject to punishment. I certify by placing a check in this box, that I have reviewed the report and that the information provided is true, accurate and complete.

You must state your name and title below. Reports that are not properly certified will be emailed back.

_______________________________________ __________________________________________ Name and title of officer (please print) Signature of officer

Sworn and subscribed to before me this __________day of ______________________ , ____________

__________________________________________ Name of Notary Public (please print)

Month Year Affix Seal Here

Form LGCCC 8B-A (Rev. 4/6/16)

__________________________________________ Signature of Notary Public